Insurance Citizens Application

INSURANCE CITIZENS APPLICATION

Applicant / Insured Information

Date of Birth:

Policy Details

Desired Policy Type (select all that apply):
Personal Auto    Homeowners    Renters    Life    Commercial General Liability    Umbrella

Proposed Policy Period: From to

Coverage Selections & Limits

Primary Liability Coverage:

Medical Payments:    Property Damage:

Additional coverages requested (check to include):
Collision    Comprehensive    Uninsured/Underinsured Motorist    Personal Property Replacement Cost    Business Property Coverage

Exclusions

The policy does not cover losses arising from willful or criminal acts, intentional loss, wear and tear, war, nuclear hazard, or loss arising from use of a vehicle for hire unless specifically endorsed. Applicant acknowledges these common exclusions and must list any additional circumstances to be excluded below.

Beneficiary Designation

If applicable, designate payable beneficiaries for life or other applicable coverages. Percentages must total 100%.

Underwriting & Claims History

Have you had any insurance claims, losses, or accidents in the last five years?    Yes    No

Has any insurer canceled or refused to renew a policy for you in the past five (5) years?    Yes    No

Required Documentation Checklist

Please attach or provide the following where applicable (check included documents):

Photo Identification    Loss History / Claims Report    Property Photos    Vehicle Registration / VIN    Financial Statements

Declaration and Certification

By signing below, the Applicant warrants that the information supplied in this application is true and complete to the best of the Applicant's knowledge. The Applicant understands that material misrepresentation, omission or concealment of information may result in denial of coverage, rescission of the policy, or voidance of claims.

The Applicant authorizes the insurer and its agents to obtain and verify information from third-party sources, including but not limited to prior insurers, claims databases, motor vehicle records, and other consumer reporting agencies as necessary for underwriting, rating, and claim handling. The Applicant further authorizes release of relevant records to reinsurers and regulatory authorities as required.

Submission of this application does not bind the insurer to issue a policy. Coverage, limits, terms, endorsements, and effective date will be set forth in the policy documents issued by the insurer. Premiums quoted are estimates and are subject to verification and adjustment based on underwriting review.

Fraud Warning: A person who knowingly and with intent to defraud an insurer submits an application or files a claim containing false or misleading information may be subject to criminal and civil penalties under applicable law.

Signature

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